Healthcare Provider Details

I. General information

NPI: 1366567471
Provider Name (Legal Business Name): MOHAMMED HOSAM ALDIN BACCORA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 3RD ST SE STE 300
PUYALLUP WA
98372-4511
US

IV. Provider business mailing address

1701 3RD ST SE STE 300
PUYALLUP WA
98372-4511
US

V. Phone/Fax

Practice location:
  • Phone: 253-697-4740
  • Fax:
Mailing address:
  • Phone: 253-697-4740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00049133
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD00049133
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: